ICH Subarachnoid hemorrhage

Posted On May 3, 2020

This review will discuss the nontraumatic subarachnoid hemorrhage, which consisted of about 3% of all acute stroke.

Cause: Cerebral aneurysm

Clinical

  • Sudden onset severe headache
  • Neck stiffness
  • May occur during activity or rest

Hunt & Hess Scale

  • Grade 1 – Asymptomatic, or mild headache and neck stiffness
  • Grade 2 – Severe headache, stiff neck, no neuro deficit except cranial nerve palsy
  • Grade 3 – Drowsy or confused, mild focal neuro deficit
  • Grade 4 – Stuporous, moderate or severe hemiparesis
  • Grade 5 – Coma, decerebrate posturing

Testing:

  • CT head,
    • if done within first 6 hours of onset, close to 100% sensitive.
    • done within 24 hours, about 90% sensitive
  • If CT is negative, LP may be considered, or proceed with CTA.
  • If onset over 2 weeks, need CTA or MRA of head.

Management

  • Transfer to tertiary care center with neurosurgery, endovascular specialists and neuro intensive care.
  • Blood pressure
    • maintain systolic < 160 or mean BP < 110
    • avoid vasodilators, no nitroprusside, nitroglycerin
  • Antiplatelets reversal: if patient is on antiplatlet
    • single dose of desmopressin DDAVP iv at 0.4 mcg/kg
    • For platelet count < 100,000, platelet transfusion 1 apheresis unit
  • If on warfarin or NOAC
  • General Care
    • Cardiac, neuro, hemodyamic monitoring
      • Monitor for pulmonary edema, cardiac arrhythmia
    • Swallow eval
    • Deep vein thrombosis prophylaxis with SCD
    • Nimodipine 60 mg q4 hour po or NG
    • Seizure and Anticonvulsant
      • Prophylactic anticonvulsant using Dilantin is controversial, consider Keppra
      • 6-18% have seizure
      • EEG to check for nonconvulsive seizure
    • Hyperglycemia management
    • Pain control
      • avoid aspirin
      • use Acetaminophin, Tramadol codeine
    • Treat fever and infection
    • Stool softener

Prognosis is based on

  • Level of conscious on admission
  • Age
  • Amount of blood on initial head CT

Specialized treatment

  • Aneurysm:
    • surgical clipping or endovascular coiling is the only effective treatment to prevent rebleeding
    • preferably performed as early as feasible, within 24 hours
  • Hydrocephalus and Increased intracranial pressure
    • may need intracranial pressure monitoring
    • External ventricular drain (EVD), monitor for infection
    • Osmotic therapy, diuresis
    • Hemicraniectomy
  • Vasospasm and cerebral ischemia:
    • usually begin 3 days after onset
    • peak at 7-8 days
    • nimodipine, euvolemia
    • large artery focal spasm: balloon angioplasty, intrarterial vasodilator are options
  • Hyponatremia, SIADH
    • maintain euvolemia
    • free water restriction